kcfd internal investigation into the line of duty deaths

7/26/2019 KCFD Internal Investigation into the Line of Duty Deaths

1/71

Internal Investigation into theLine of Duty Deaths

Fire Apparatus Operator Larry Leggio

Firefighter John Mesh

October 12, 2015

2608 Independence Avenue


2/71

Dear Colleagues,

The Kansas City, Missouri Fire Department has a proud and long history of serving the citizens and

visitors of this City. The members of KCFD have committed unselfishly to putting their lives on the lineevery day. On October 12, 2015 Fire Apparatus Operator Larry Leggio and Firefighter John Mesh losttheir lives in the line of duty. I have assigned an internal investigation team to construct a report whichcontains the facts and issues surrounding this event. The report covers the incident from the time ofdispatch to the moment of collapse which took the lives of our brothers and friends.

This document is not intended to lay blame or find fault, it is simply a compilation of facts and data,

wherein we can learn and hopefully prevent a similar incident from occurring.

I would like to thank the families of FAO Larry Leggio and Firefighter John Mesh. Because of the danger

inherent with fighting fires, these families have endured the ultimate sacrifice. The spirit of these twoindividuals and their tremendous contribution to their respective stations, co-workers and members of the

department will never be forgotten. We the members of the Kansas City, Missouri Fire Department trulyhave had the honor to serve with FAO Leggio and Firefighter Mesh. Both of these gentlemen nevercomplained but understood the importance of what is asked in the line of duty to the community in which

we serve.

I am proud of what the members, residents, and governing body of Kansas City, Missouri have done tosupport this Fire Department. I would first like to take this opportunity to personally thank the members

of this department. Your dedication, devotion, and allegiance to the citizens of the city, to one anotherand the overall department, ensure that we will continue to heal from this tragic event. I also thank thecitizens of Kansas City, Missouri for their continued support of the Kansas City, Missouri Fire

Department. The outpouring of public support was overwhelming to the members of our department andthe families of our dear brothers. I thank those who took the time to ask their questions and havediscussions about how to better their fire department.

I would further like to thank the members of the KCFD Investigation Team for their commitment in

spending many hours working on this investigation. Donating their time within their busy schedules andutilizing their collective talents, is greatly appreciated.

It is my belief that in providing a report which contains the facts, issues and how the department has

responded in the aftermath is the most important service we can deliver to our citizens and the men andwomen of the Kansas City, Missouri Fire Department.

Sincerely,

Paul Berardi

Fire Chief


3/71


4/71

International Association of Fire Fighters

Local 3808 Kansas City Chief Officers

2800 Cherry

Kansas City, MO 64108

Fellow Brothers and Sisters, Colleagues, and Professionals;

On October 12th

, 2015 the Kansas City, Missouri Fire Department experienced a stunning

loss. Two of our dedicated brothers and friends of mine perished while battling a blaze in OldNortheast. This is not the first tragedy our department has had to face in its long, lustrous history

nor will it likely be our last.

With that being said our Fire Chief and Locals 42 and 3808 have teamed up to create a

body to review the events of October 12th

to come up with recommendations in the hope we can

forestall any tragedy such as this from touching our lives again. This group of members andmanagement has devoted countless hours of work to complete the task that was asked of them.

The stacks of reports and standards to review seemed insurmountable in themselves. Couple that

with the firsthand accounts from the After Action Review and the information from the Bureau

of Alcohol, Tobacco, and Firearms and you get an idea of the massive task load of the workinggroup. In addition to that task load was the emotional weight this incident carries and the

personal nature of which many on the group knew the fallen. I want to thank each member of the

group for doing a job that was exhausting, heart breaking, and what I hope will be worth all of

the sweat and tears that were shed in this endeavor.

The intent of this report is not to condemn any person who was on the scene the night of

the fire but instead to learn from this tragedy and move forward as a group better than we werebefore. Larry and John can continue to contribute to the jobs they loved so much in this

document and the memories of those who knew them.

My condolences go out to Stations 10 and 17, the members who were close to the

brothers, but most importantly to the Mesh and Leggio families. There is not a day I dont think

of you and the sacrifice you made. This document is dedicated to all of you in the hopes wenever have any such disaster strike us again.

Clay Calvin

President

IAFF Local 3808


5/71

Kansas City Fire Department Internal Investigative Team

One Team, One Job, One Mission

Member(s) Bio

FAO LARRY LEGGIO

Last Alarm October 12th, 2015

FAO Larry Leggio died October 12th

, 2015, as a result of injuries sustained in the line of

duty, at a multi alarm response to a building fire at 2608 Independence Avenue, Kansas City,Missouri. Larry was assigned as a Fire Apparatus Operator on Truck 2, akaThe Deuce, C shift.

Larrys father, Angelo Leggio, was a 17-year veteran of KCFD. Growing up Larry was

fascinated by this line of work and dreamed of becoming a firefighter. In May of 1998, Larry

was hired by KCFD and this dream became a reality. His first assignment at Station 23 on

Independence Avenue allowed him to work in his childhood neighborhood. As his career

progressed, Larry was moved to Station 17, where he remained until his passing on the tragic day

of October 12th

, 2015.

Aside from fighting fires, Larrys dedication and loyalty was with his wife Missy, his family,

and his close friends. Together, Larry and Missy enjoyed everything from family vacations to

charity motorcycle rides. The eagerness Larry had when he began his career as a firefighter never

dwindled. Missy shared this eagerness and love, watching her husband doing the job he loved

with the people he loved. Throughout the Kansas City Fire Department, many Brothers and

Sisters came to know them both as family.

Larrys outgoing personality, recognizable smirk, and active participation in Union events and

charity functions made him well-known and well-liked on the job. Larry genuinely and whole

heartedly embodied the titlefirefighter, which he carried with an unassuming, natural pride. This

loss is felt from those that knew him best to those he met only for moment, as even brief

interactions with Larry were often memorable. He could easilybring a smile to anyones face

and, despite his passing, we will continue to smile as we look back on our time spent together.

The International Association of Firefighters, Locals 42 and 3808 and The Kansas City Fire

Department extend their deepest condolences to the family of Larry Leggio and to his Brothers

and Sisters on the Kansas City Fire Department.


6/71



Member(s) Bio

FF JOHN MESH

Last Alarm October 12th, 2015

Firefighter John Mesh died October 12th

, 2015, as a result of injuries sustained in the line ofduty at a multi alarm response to a building fire at 2608 Independence Avenue, Kansas City

Missouri. John was assigned as a firefighter on Pumper 10, B shift.

John was born and raised in Old Northeast in Kansas City. John was the youngest of eight

siblings. He married the love of his life, Felicia, and together they had four beautiful daughters.

Hunting was one Johns favorite hobbies, something he shared with his father and brother, and

was passing on to his daughters. John was proud of all of his girls, and was active in all their

school and extracurricular events. John was the complete embodiment of family-man.

In 2002, John became a firefighter with the Kansas City Fire Department. When he wasnt

around family or friends, John was quiet and reserved, though it didnt take long to figure out

what type of person he was. John was humble, polite, and modest. His coworkers and family

knew him as a strong, brave, highly intelligent person who was proficient in his job and vigilant

when it came to the safety of his crew, though he would never openly admit to any of those

things. John was the guy everyone knew they could depend on, whether that meant help at the

station or in the midst of a working fire. John was a firefighters firefighter who was a leader

both in the firehouse and on the fireground. He was the guy you wanted to see when you turned

around. John was assigned to Pumper 10, B shift where he remained and had been working on a

shift trade on the tragic day of October 12th

, 2015.

The International Association of Firefighters, Locals 42 and 3808 and The Kansas City Fire

Department extend their deepest condolences to the family of John Mesh and to his Brothers and

Sisters on the Kansas City Fire Department.


7/71



Table of Contents

Section Page

Acknowledgements 1

Overview of the Kansas City, Missouri Fire Department 4

Organization Chart 5

Executive Summary 6

Incident Summation 8

Scene Map 9

The Fire Structure 10

Contributing Factors 15

Recommendations 29

Closing 33

References 34

Glossary of Terms 35

Appendix A 41

Appendix B 62

Appendix C 63


8/71


1One Team, One Job, One Mission

Acknowledgements

The Kansas City, Missouri Fire Department wishes to thank the following individuals for all

their efforts and dedication through the difficult process of examining the circumstances

involved in the line of duty deaths occurring October 12, 2015. The Kansas City, Missouri FireDepartments goal is to identify any causal factors and recommend appropriate corrective actions

as it pertains to this tragic event.

KCFD Investigation Team Members

Assistant Chief of Department Jeff Grote

Team Leader and Investigator

Union Local 42 Designee

Captain Gary Reese

Union Local 3808 Designee

Battalion Chief James Walker

Deputy Chief Todd Ackerson

Deputy Chief Vincent Boucher

Deputy Chief Jeff Johnson

Battalion Chief Damon BarkleyDocument Group

Battalion Chief Peter Knudsen

Document Group

Battalion Chief Brian Trickey

Document Group

Union Local 42 Business Agent Justin AbrahamDocument Group

Sheryll Wilson

Recorder of Record


9/71



Special Acknowledgements

FireFighter Fatality Investigation and Prevention Program Division of Safety Research

National Institute for Occupational Safety and Health

Investigator Murrey E. LoflinGeneral Engineer Matt Bowyer

Occupational Health and Safety Specialist Steve Miles

(ATF) Bureau of Alcohol, Tobacco, Firearms and Explosives

Lead CFI Ryan ZornesGroup Supervisor Eric ImmesbergerNRT Team Supervisor Chris Porreca

Scene Fire Protection Engineer Adam St .John

Lead Coordinator CFI William Marshall

Lead Coordinator CFIC Robert Looper

Photographer CES/CFIC Brian LovinOrator CFI Donna Slusser

Scene/Forensic Mapping Lenwood ReevesScene/Forensic Mapping Ken Whiteley

Safety Officer Kelley Etinier

Scene Chemist Meghan MillerScene/Electrical Engineer EE Mike Keller

Scene/Electrical Engineer Richard Alarcon

Scene/Medic Donnie MannPIO John Ham

Peer Support/Scene Jon Hansen

Lead/Interpreter Hoang Nguyen

Forensic Auditor/Interpreter Nicole Nguyen-MurleyTechnical Surveillance Specialist Steve Greene

Polygrapher Chase Bynog

And the many other ATF Personnel

Kansas City Missouri Police DepartmentMajor Joe McHale

Major James Connelly

Major Robin Houston, K-9Master Patrol Officer Erich Hellerich

Captain Daniel Gates

Captain Michael Perne

Captain Roy TrueSergeant James Gottstein

Sergeant Ronald Podraza

Sergeant Kari ThompsonSergeant Mark Bentz


10/71



Special Acknowledgements (contd)

Sergeant Eben HallSergeant William Hewitt

Sergeant Dan Mairet

Sergeant Matthew PayneSergeant Bryan Truman

Detective Terry Carter

Detective Rick HulmeDetective Sondra HultsDetective Bryan Jobe

Detective Lowell Lacy

Detective Mike LusterDetective Greg Mosier

Detective Chris Skinner

Detective Jay Thompson

Detective Lex WallaceAnd our many Police Officer Brothers & Sisters

Civilian Lynsay Holst

Kansas City, Missouri Police Departments Bomb and Arson Unit

Missouri State Fire Marshals Office

Missouri Search and Rescue (MOSAR)

Industrial Wrecking Company

Belger Cartage Service Inc.

Kansas City Public Works

Kansas City Power & Light

Fire Investigator Division of the Kansas City, Missouri Fire Department

We are indebted to all of our colleagues who aided in the compilation of this narrative. Your

insight, expertise, and resources greatly assisted in the conducive conditions of the investigativeteamsassignment. The investigative team wishes to thank the following KCFD companies;

Truck 2, Truck 5, Truck 6, Truck 12, Rescue 9, Pumper 23, Pumper 24, Pumper 27, Pumper 35,

the KCFD Communications Center and Command Staff. These personnel unselfishly gave their

time to provide factual information and eyewitness testimony. Without this information, much

of this report would not have been possible. Their input was and is valued and greatly

appreciated.


11/71



Overview of the Kansas City, Missouri Fire Department

The Kansas City, Missouri Fire Department consists of uniformed and civilian employees who

provide fire protection, emergency medical service, emergency rescue, hazardous materials

response, and community risk management for the residents of Kansas City, Missouri. The

Department stands committed to deliver their very best with each opportunity to serve.

Led by Fire Chief Paul Berardi, KCFD delivers emergency services to the citizens of KansasCity, Missouri across 319 square miles from 34 fire stations that are organized into seven

battalions. The departmentsintegrated system of response includes fire apparatus and

ambulances stationed strategically throughout the city. This system is designed to place fullytrained emergency medical technicians quickly at the patients side in any life threateningemergency. Every emergency responder in our system, whether riding a fire engine or an

ambulance is trained to the EMT level or beyond to ensure that care will always be available.

The department responds to approximately 110,000 emergency calls per year.

The department is organized into bureaus that include: Professional Development, TechnicalServices, Special Operations, Emergency Operations, Systems Support and the Emergency

Medical Bureau. An Assistant Chief of Department or Deputy Chief manages each of thebureaus.

A hallmark of the department is the Labor/Management Partnership program that exists amongfire administration and both locals of the International Association of Fire Fighters. This

partnership is designed to include the employees as a participant in every significant decision

within the department concerning policies and programs.

Mission

KCFD provides compassionate, professional life safety services by responding to the needs ofthe citizens and visitors of Kansas City, Missouri and its greater metropolitan area. Our services

are enhanced through training, education, planning and teamwork. We will achieve our missionsafely through the effective and efficient use of all resources.

Personnel & Equipment

The department includes more than 1200 emergency response and support personnel. TheKansas City, Missouri Fire Department has a daily deployment to serve the nearly 470,000

citizens of Kansas City, Missouri that includes:

-

34 Pumpers - 3 Technical Rescues 10 ALS Pumpers - 12 Aerial Apparatus

24 BLS Pumpers - 27 Dynamic ALS Ambulances- 19 Static ALS Ambulances

- Various specialized support equipment (Air support, HazMat Rescue)


12/71



KCFD Organizational Structure


13/71



Executive Summary

This Line of Duty Death (LODD) Investigative Report is dedicated to FAO Larry Leggio and FF

John Mesh, and to the families, friends, and coworkers of these two brave men. These two

Kansas City, Missouri firefighters will never be forgotten for their supreme sacrifice. The

Kansas City, Missouri Fire Department is committed to share this investigative report with thedepartment and the fire service so that organizational learning can occur. It is our hope and

genuine desire that the findings from this report will be utilized and employed in a manner to

ensure that a tragic incident such as this one never happens again.

The findings in the investigative report were derived by applying a multi-dimensional team

approach. The charge for this investigation included the construction of a final report to be

presented to the Fire Chief, outlining the facts of the incident, the identification of causal factors,

and recommendations for appropriate corrective actions. The following bullets present the

investigation objectives:

Identify factors which resulted in the Line-of-Duty-Deaths (LODD)

Identify situations that involve unacceptable risk

Identify previously unknown hazards

Identify inadequacies in training, policy or performance

Ensure lessons learned are communicated to effectively prevent future accidents and

injuries

Identify professional standards to be used/applied in the construction of departmental

policy

Alcohol, Tobacco, and Firearms (ATF); the Kansas City, Missouri Police Departments Bomband Arson Unit; the Missouri State Fire Marshals Office; and the Fire Investigation Division of

the Kansas City, Missouri Fire Department worked collaborativly to determine the origin and

cause of this fire. The joint task force conducted interviews and dissected the structure to analyze

every aspect and every component of this incident. This exhaustive process encompassed 9 days

of scene and witness review. The findings of this joint task force were utilized by this

investigative to establish facts and compose recommendations..

On the evening of October 12, 2015 FAO Larry Leggio and FF John Mesh were fatally injured in

a wall collapse at a structure fire that was dispatched at 7:27 pm. The fire involved a three story

Type III structure with apartments located on the second and third floors. The first floorcontained four commercial spaces, three of which were occupied and open for business on the

date of this incident.

Initial regular alarm companies reported heavy smoke and commenced rescuing residents from

the upper floors of the structure while attempting to determine the location and seat of the fire.


14/71



After 19 minutes, 38 seconds of interior operations, the Incident Commander ordered an

evacuation and switched operational tactics from offensive to defensive.

Shortly after this change in tactics, the Incident Commander ordered that a collapse zone be

established. At 8:06 pm, firefighters were operating inside a collapse zone when the D-side

masonry wall collapsed. Four firefighters were transported emergency to area hospitals and twoof these men passed away from their injuries. Several firefighters reported injuries resulting

from the collapse, and two of these firefighters are undergoing extensive rehabilitation from

injuries sustained.


15/71



Incident Summation

On October 12, 2015, at 7:27 pm, the Kansas City, Missouri Fire Department (KCFD)

dispatched a regular alarm consisting of 3 pumper companies, 2 truck companies, 1 ALStransport medic unit, and a Battalion Chief. The staffing per apparatus is a minimum of 1

officer, 1 FAO, and 2 firefighters for fire suppression units and 1 EMT and 1 paramedic for the

ALS transport unit.

Upon arrival at 7:29 pm, the first KCFD unit reported heavy smoke showing from the rear

(North side, C-side) of the structure, established command, requested a working fire response,

and then stretched a 1 -inch, pre-connected hand line to begin fire attack. There was a report of

civilians trapped and the first and second arriving truck companies began rescue of occupants

from windows and stairways.

Command was assumed by the first due Battalion Chief (Incident Commander or IC), who then

requested a first alarm and reported heavy smoke conditions from a large structure with mixed

occupancies. The building addressed as 2608 Independence Avenue was a three story, mixed

occupancy that has four commercial occupancies located on the first floor; it is of Type 3

construction. The second and third floors were wood frame, balloon construction. All of the

commercial occupancies were accessible from the south side (street side).

Upon arriva,l there was little to no smoke visible and no fire showing. There was one (south side,

A-side) entrance that provided access to the second floor apartments, however they were not

marked as such. Located at the rear (north side) of the building was access to all three stories

with easy access to the second and third floor apartments. The first floor commercial

occupancies were accessible on the north (C- side) with the exception of the unit of fire origin,

which only had access from the south (A-side).

Fire companies operating under extreme heat and smoke conditions were able to rescue two

occupants from the structure. They then provided a primary search after the rescues and reported

all-clear. Firefighters detected several locations throughout the building where fire conditions

were becoming untenable, and reporting great difficulty in locating the main seat of the fire.

Based on this information a second alarm was requested by the incident commander.

Approximately four minutes later, the IC ordered evacuation of the building. Dispatch confirmedthe order and provided alert tones repeating the ICs request for aPersonnel Accountability

Report (PAR). All companies responded with reports that all personnel were accounted for. The

first arriving EMS supervisor completed a face-to-face briefing with the Incident Commander

and established an initial treatment sector on the A-side of the structure. A medical branch was

established to address any expanding medical needs.


16/71



Scene Map


17/71



The Fire Structure

The departments internal investigation team attended a presentation by the Bureau of Alcohol,

Tobacco, Firearms and Explosives (ATF) on January 29, 2016, regarding their investigation intothe incident. This presentation provided valuable and detailed insight into the factors that

leading to this tragic event. This fire was found to be intentionally started. It is the consensus of

this investigation team that this fire was started in what was very likely the worst possible

location for civilian, firefighter, and building survivability. Information supplied below

regarding building construction has been compiled after reviewing various agency reports

regarding this incident and past incidents involving building collapses.

The earliest city records show that this building was erected in 1925. It was a 3-story Type III,

ordinary constructed building with four commercial spaces on the first floor. The measurements

of this building were 64 by 216 feet on the ground floor, which equates to 41,472 total squarefeet. There were an additional 16 apartments located on the second and third floors. This

structure did not contain a sprinkler system or a centrally monitored fire alarm system. Several

of the apartments on the second and third floors contained single station smoke detectors.

Commercial Spaces

The first floor contained four commercial occupancies (2606 - 2618 Independence Avenue);

Jackson Hewitt Tax Service, Gracies Store, LN Salon and Spa, and an unoccupied space.

(Picture 1)


18/71



The first floor was built upon a concrete slab. The upper floors were supported by ceiling joists

that ran from east to west within the building. There were four large I-beams that ran north and

south that the ceiling joists rested upon. These I-beams were supported by tubular steel columns

located throughout the first floor of the structure. It is important to note that the I-beams and

joists were located within a concealed space which ran the span of the structure. Additionally,

the tubular steel columns were exposed and unprotected on the first floor.

(Picture 2)

The Apartments

The second and third floors were balloon construction with a vertical vent shaft running the

length of the structure (see location below). The shaft originated in a wall space between LN

Salon and Spa and the vacant occupancy directly east of LN Salon and Spa. The main entrances

into the apartments were located on the C-side of the structure through two main access points.

It is important to note that there was an additional entrance to the apartments via a stairwell

located on the A-side of the structure.


19/71



(Picture 3)

Building Components

The exterior walls were constructed as outlined below:

A-side the three story front of the structure was masonry constructed with some

portions of the second and third floors containing a stucco decorative finish.

B-side this wall was shared on the first floor with an additional building (Speedy

Loans, not part of this report). It was constructed with a clay tile and brick.

C-side this wall had several characteristics. Visually, this side of the structure looked

like two stories due to the grade of the lot. However, this building contained a below

grade walkway that opened into the rear of the commercial occupancies on the 1stfloor.

This wall was constructed of clay tile and brick, with the second and third floors covered

with wood siding.

D-side this wall was constructed with clay tile and brick. There were no entrances to

the building from this side of the structure. There were several apartment window

openings and 3 openings to the unoccupied occupancy on the first floor.

Unreinforced masonry walls are typically several wythes thick. This can visually be determined

by viewing bricks laid with the butt end on the exterior face of the wall; this ties the wythes of

bricks together.


20/71



(Picture 4)

Roof

The roof was comprised of several dormers and roof gables that can be seen in the aerial and

exterior photos of the structure. The remainder of the roof was flat with a parapet wall around

the perimeter. Utility services mainly entered the structure from C-side. There was a separate

structure due north of the fire building that housed the steam furnace for the structure.

Division A

2608 Independence Avenue

Division

D


21/71




22/71



Contributing Factors

The internal investigation team applied an error-based research procedure to determine the most

accurate framework by which elements of this incident could be highlighted and discussed. For

analyzing firefighter near-miss reports, the following criteria are utilized to determine and

recognize causal factors that resulted in the Line-of-Duty-Deaths. These criteria represent alarge body of research that was first developed by the Department of Defense to study and

analyze aircraft accidents. This system is called the Human Factors and Classification System

(HFACS). This system is utilized as a tool to assist the investigative process and highlight

targeted training and prevention efforts recommended for KCFD.

Below is a comprehensive human error framework which was selected by firefighter near-miss

reporting system. Below are 18 causal categories related to the four levels of human failure:

1. Unsafe Acts

Situational Awareness Communication

Teamwork

Individual Action

Task Allocation

Human Error

2. Pre Conditions to Unsafe Acts

Weather

Fatigue

Accountability

3. Unsafe Supervision/IMS

Inadequate Supervision Planned Inappropriate

Operations

Failure to Correct Known

Problems

4. Organizational Influences

Training issues

Staffing

GAG/GOG

Policy/Procedure

Equipment

Limitations

~ Unsafe Acts ~

Situational Awareness

Situational awareness is developed differently among a wide range of firefighters. Experience,

education, and departmental policy are all elements that develop situational awareness. Couple

these elements with knowledge previously gathered regarding the incident, as well as new

information as it is received, and one begins to develop situational awareness. The overall

foundation of situation awareness is determining risk versus reward and making incident

appropriate tactical assignments.

The 2608 Independence Avenue incident contained several critical elements that shuld typically

prompt enhanced situational awareness. A large portion of the firefighters had responded to a

previous structure fire in this building about 10 months prior to this incident. This information


23/71



was utilized by the first arriving companies and the majority of resources responded to the rear or

C-side of the structure; knowing that this was the primary entrance into the apartments on the

second and third floors that presented the greatest life hazard. The initial size-up upon arrival

indicated heavy smoke. Several company officers stated in the after action review that they

were surprised that a fire would be that advanced so early in the evening. This was a critical

incident factor revealing that the fire had transitioned past the incipient stage well before the

original dispatch or 911 call.

Company officers had previously pre-planned this structure and determined in many

cases it would be best to utilize the C-side of the structure for fire attack. The C-side of

the structure was the main entrance for the apartments and the second and third floors.

Citizens were motioning for assistance in the rear of the structure on arrival.

Previous knowledge also assisted in the determination of C-side fire attack.

A well involved fire was indicated by the size-up provided by the first Incident

Commander. This is the type of information that should be utilized when determining

time sequencing for offensive tactics.

Transfer of command was completed twice during this incident, and three distinct individuals

held Incident Command at least once during this incident. There are basic tenets that must be

completed before a transfer of command is to take place. The fundamental premise is that all

transfers of command take place face to face. During this incident the face to face transfer

of command did not take place during the first transfer of command.

In conjunction with the departments IMS manual, the first arriving officer assumed

command and employed the fire attack mode, directing fire attack on the C- side of

the structure.

First arriving chief officer assumed command and began IC operations on the C-side

of the structure.

First arriving deputy chief conferred with IC and assumed command. He established

the command post on the A-side of the structure.

Upon arrival, the ranking deputy chief began to organize resources and tactics that centered upon

a large defensive commercial structure fire. The Incident Commander ordered that all chief

officers report to the Command Post for instruction and assignments. Additionally, the Incident

Commander began to divide the incident into divisions with assignments made to each side ofthe structure. Also upon arrival, the ranking deputy chief began to consider building collapse.

The Incident Commander requested tones from the communication center and ordered that a

collapse zone be established. The communication center received and repeated the Incident

Commanders message with informational tones.


24/71



The ranking officer began to establish a working Incident Action Plan that assigned

chief officers to specific roles.

The ranking officer established a collapse zone.

Upon visual determination that firefighters were operating within the collapse zone he

began to verbally order the evacuation from the D-side alley, just seconds before the

wall collapsed.

Between the moments of 7:57:40 pm and 8:02:26 pm, per the radio log, aerial master stream

operations from the C-side of the structure were commenced. The collapse of interior floors and

D- side of the structure occurred at 8:06:11 pm. This was the only reported aerial stream in

operation prior to collapse, though interior hand lines had been in operation for several minutes

prior to evacuation at 7:49:19 pm. Applied water can add significant weight to a structure,

though it is unknown if this was a contributing factor to the timing and location of the collapse.

Situational awareness must be conducted by all personnel operating at emergency incidents.This process searches for signs and information that can be employed when determining strategy

and tactics. Items that should be communicated to all those at the scene are obvious safety

concerns, building degradation or structural movement, and human injury or rescue.

Communication

The investigation into this event included a review of all audio recordings of the event, personal

interviews, and information gathered from the departments formal AAR regarding this incident.

The departments communication model is not consistently utilized by communications and

emergency personnel. Should messagesbe transmitted utilizing the You, this is me

foundational concept on all communications? The organization must identify and adhere to a

prescribed communication model. Without this, communications may not be heard, may be

dropped, or may be misunderstood. Emergency scenes are dangerous on their best day and a

system should be adhered to that everyone understands. Missed communications can lead to

disastrous results. Information gathered from the formal AAR highlights that a number of the

companies operating on the scene did not hear the Collapse Zone Order issued from command.

Teamwork

Within the fire service profession there are countless standards, polices, textbooks, and articles

that stipulate that tasks performed on the fire ground be conducted in a minimum of a two person

team. The investigation team did not find any instances of personnel operating outside the scope

of this professional standard except for the district safety officers who were operating within

cultural norms.


25/71



Individual Action

The investigative team recovered documents that included interviews of the firefighters on the

scene, reviewed information gathered from the formal After Action Review, and analyzed audio

recordings to reach their determination under this category. It was found that no select

individual action was a determining factor in the masonry wall collapse.

An element of company action was discovered in the course of this investigation that warrants

mention. There were instances in which KCFD companies self-dispatched to the fire scene.

Self-dispatching has the potential to derail the process of accountability and order that the

Incident Commander and Communications staff so desperately need while mitigating chaotic

emergency scenes. At this scene, there is no negative impact from these actions, but at any

incident (where a May-Day could occur) the extra burden of that disorder could lead to tragic

results.

During this incident and immediately following the wall collapse staging companies self-reported and self-assigned tasks. When serious events transpire at any emergency scene,

resource tracking becomes paramount. When the collapse of staging occurs, inadequate resource

tracking is the inevitable result.

Task Allocation

Throughout this incident there were a multitude of tactical assignments that were issued and

completed. On almost every fire scene it is common for resources to be split to perform tasks

such as two truck firefighters assigned interior to the structure to perform a search and two truck

firefighters assigned to the roof to ventilate. This happens routinely on all emergency incidents

and is a normal procedure.

The tactical decision to place resources within the collapse zone was communicated over the

radio by the division chief officer after his conversation with a fire apparatus operator that was

located on the D-side of the structure. This message was not confirmed by the Incident

Commander. The task consisted of stretching and directing a hose line from the corner of the D-

side of the structure and to place a water stream into two openings that were showing aggressive

fire. It was reported from the crews on the D-side of the structure that fire was impinging upon a

fire apparatus that was spotted in the alley. The resources assigned to complete the tasks by the

division chief officer were sufficient to complete the task.

Human Error

There is a significant cultural error that takes place on large incidents. Once the overall incident

objectives have been switched to defensive from offensive, several critical things occur.

Firefighters exit the involved structure and conduct Personal Accountability Reports (PAR).

Once the all-clear has been broadcast by the communications center, a certain level of scene


26/71



safety is diminished. Firefighters gather close to their apparatus and begin to remove their

SCBAs and prepare for defensive operations. Medical indicators such as blood pressure and

pulse rate all start to decrease at this stage in the incident. Unfortunately, at this point the

firefighters began to feel that their personal safety had drastically increased from the time they

were inside the structure. Almost always this instance is true; it is safer outside of a burning

structure than being on the inside.

The increased sense of safety on the exterior of the structure was a factor at this incident. This

flawed safety sense allowed for the tactical decision to perform and maintain operations within

the alley on D-side of the structure. The alley on the D-side of the structure was utilized as a

primary avenue of travel for those personnel at the incident until the collapse of the wall. There

was one fire apparatus parked within the collapse zone on the D-side. Immediately following the

command staff meeting at the command post on the A-side of the structure, 3 officers utilized the

alley to reach the location of their assignments. Ultimately, the D-side of the structure was not

critically evaluated as an immediate danger to firefighters in the area and proper consideration of

wall collapse was not recognized by most firefighters at the scene.

~ Preconditions to Unsafe Acts ~

Weather-Fatigue

Weather cannot be considered a contributing factor for these investigations, after reviewing the

information provided from the National Weather Service (NWS), it outwardly does not seem to

have an effect on this incident. Weather conditions recorded that night at 7:30 pm were in the

middle to upper 60s with the winds steady out of the west at less than 5 mph. At 8pm the NWS

reported a slight drop in temperature to the middle lower 60s with a further drop in wind speeds

to 0 with no direction registered.

In this instance, fatigue does not appear to be a contributing factor for the events and decisions

made at the fire on Independence Avenue. A run report generated for the first in companies

indicates there is no concern on the issue of crew fatigue. A TeleStaff report generated to

determine the working hours of the members suggested no critical role in the incident. Nothing

unusual was determined from the information provided for most of the key members involved.

One member was from a different shift and was trading time the day of the incident. This

member had worked an overtime shift in addition to his regularly assigned shift in the days

preceding the fire. KCFD Communications Center generated a report indicating the run volume

for the first in due companies who played a major role in the fire attack.:

Pumper 10 responded to 12 calls including the fire on Independence Ave.

Truck 3 from the same fire station responded to 4 calls including Independence Ave fire.

Truck 2 from St. 17 responded to 3 calls including the fire.

P23 responded to 7 calls, including the fire.

Truck 10 responded to 3 calls, including the fire.


27/71



Car 104 responded to 3 calls, including the fire.

Accountability

Currently, KCFD does not utilize its existing policy that addresses accountability. On the night

of the incident there was not an accountability system in place. NFPA 1521, Standard on FireDepartment Safety Officer Professional Qualifications and NFPA 1561, Standard on Emergency

Services Incident Management System and Command Safety, address the need for such a system

to be utilized by the fire departments for both emergencies as well as for non-emergency

operations.

~ Unsafe Supervision/IMS ~

Inadequate supervision

Were adequate resources ordered for this event and how did this impact span of control? The

second incident commander requested that the Communication Center not order but prepare for a

second alarm. During large scale events that require extra alarms, it is important that incident

commanders consider Level I and Level II staging of extra alarm companies so that systematic

placement of resources can occur. When the 2nd alarm was requested at this incident, a staging

location was not communicated. For the first 20 minutes of this incident 2 chief officers were

responsible for 14 companies. The Medical Branch consisted of 2 EMS supervisors and 4 ALS

transport units. Additional truck companies were ordered by the second incident commander.

Per the KCFD IMS manual, span of control is identified as between 3-7 companies for each

supervisory role. As identified in a previous section of this analysis, self-dispatching disrupts

span of control and causes confusion. It is imperative for all officers to account for resource

demands early within an incident.

Immediately following the wall collapse, a May-Day was issued by the C-side commander. This

was acknowledged by the incident commander and the Communications Center began May-Day

communication protocols along with an extra alarm level that is part of the operational May-Day

GOG.

All fire ground operations on tactical channel 5 were assigned to the new tactical channel 6 by

the communications center. This procedure insures that firefighters in trouble do not compete for

air time with companies operating on the fire ground. On-scene personnel and the incident

commander did not make the move to the designated fire ground tactical channel 6. The extra

alarm May-Day companies responded to the scene on tactical channel 6 and did not have

communication with the incident commander as he remained on tactical channel 5. The failure

to switch tactical channels caused confusion with the extra alarm May-Day companies and the

medical branch officers. All companies remained on tactical channel 5 for rescue operations.

The Communications Center quickly realized the confusion regarding tactical channels and

switched additional resources to tactical channel 5 for assignments.


28/71



The potential for communication issues during a May-Day is increased by moving fire ground

operations to a new tactical channel as prescribed by the May-Day GOG. The switching of May-

Day event is discussed in the recommendations.

Planned Inappropriate Operations

The tactical assignment that generated tragic results was placing resources on the D-side of the

structure within the designated collapse zone. This tactical assignment was critical due to fire

impinging upon a fire apparatus parked in the alley. After given his assignment by the incident

commander the division officer in charge of the D-side was confronted by a member expressing

the need to secure a water source for one of the apparatus on the D-side. At that time the chief

saw no one inside the collapse zone and no fire impinging on the apparatus; he then left the D-

side to search for a water source. Between this moment and the return of the division officer a

company officer saw fire impinging on the fire apparatus parked in the alley. It was during that

time that this company officer ordered his crew to direct their hose stream into the windows

showing fire. The hose was placed in the position of maximum effectiveness, which placed thecrew within the collapse zone. This action should be noted as an effort only to protect the fire

apparatus and was to be a temporary placement. The building showed no signs of imminent

collapse, which factored into this decision by a number of experienced personnel. Within

seconds of the return of the division officer a sudden, catastrophic collapse occurred.

Why was the apparatus in the alley?Personnel were attempting to protect an apparatus in

the alley that had been blocked from movement earlier by a utility vehicle

Had a strict collapse zone been adhered to prior to the hose line placement?No. A

number of individuals, including chief officers, had travelled to various areas on the fire

ground via the alley. Why were personnel allowed to operate on the D-side? There were many places on the

D-side which afforded a safe vantage point to protect exposures and extinguish the fire.

Personnel on the D-side operated safely outside the collapse zone until minutes before the

collapse when the fire began impinging upon the apparatus.

Failure to Correct A Known Problem

The investigative team identified failures to correct a known problem that occurred during the

incident.

The most significant was personnel operating in the alley. Once this was identified, theincident commander immediately began radio traffic to remove personnel from the alley.

Before the communication could be completed, the wall collapsed on the personnel.

The alley was utilized as the main path of travel to reach the C-side of the structure by the

majority of personnel on the scene. Officers leaving the command staff meeting, in

which the collapse zone order was issued, utilized the alley to reach their assignments.


29/71



This dovetails with the earlier discussion regarding the lack of understanding and

implementation of collapse zones.

Several fire apparatuses were positioned within the collapse zone. There was

consideration given to moving the fire apparatus in the alley once defensive tactics were

being prepared.

The other identified failures to correct did not have a significant impact on this incident but

require work by the department to correct going forward.

~ Organizational Influences ~

Training Issues

Training is defined as the effort to increase the knowledge, skills, and abilities (KSAs) of

employees and managers so that they can better do their jobs. The investigative team has

highlighted several areas within the auspice of departmental training that are causal factors. The

department relies predominantly on company level training on a daily basis and rarely performs

multi-company training or annual training in areas such as situational awareness, resource

management, building construction, tactics, and the IMS system

The training records for FAO Leggio and FF Mesh were accounted for from the Fire Training

Academy and the EMS Training Division. Both employee records reflect certifications from

either the Division of Missouri Safety for Firefighter 1&2 or the equivalent from the authority

having jurisdiction (AHJ). Numerous other State of Missouri certifications were noted in their

training files. The knowledge employed by both of these firefighters is hard to measure. Both of

these firefighters worked in high call volume areas and were assigned to busy fire companies.

Staffing

The investigative team has concluded that staffing did not present any causal factors at this

incident in accordance with NFPA 1710. Proper staffing levels result in increased experience

and enhanced safety on emergency incidents.

GAG/GOG/Policy

An overall evaluation to identify existing policy that may have affected this incident was

performed. The following policies were examined for purpose, ability to execute, if it

contributed negatively or was not followed, and for need of revision.

FF Safety Manual

KCFD Rules and Regulations

GAG 5-1 In-Service Training

GAG 5-12 Regular Core Competency Training

GOG 11-2 May Day Communications

GOG 11-9 KCFD Accountability


30/71



GOG 11-9.1 Personnel Accountability Report (PAR) Procedures

Policy specific evaluations are detailed in Appendix C.

NOTE: GOG 10-1 KCFD IMS and GAG 3-4 Radio Communication Procedure were alsoidentified as relevant policies, but evaluated in separate sections.

Culture

Organizational culture is found throughout all spheres of society and the Kansas City, Missouri

Fire Department has a distinct culture of its own. Several of these cultural norms are addressed

in this sub-section of the analysis.

We are a tactically aggressive fire department that is proud of its tactical approach to

fires. Our aggressive nature often yields life-saving results and saves our citizens

property. Such was the case at this fire. KCFD firefighters rescued two citizens fromupper balconies on the north side of the structure during this fire fight. This aggressive

nature, however, needs to be re-calibrated to always include risk versus reward

determinants. It was noted by interior fire attack crews that some of our members were

nearly at May-Day conditions while still in the structure due to heat, many felt interior

operations had become untenable, and some were following hose-lines to escape the

structure when the evacuation orders were given. This was too close to further tragedy.

Our mangers, at times, do not manage their personnel. KCFD supervisors at every level

of an emergency scene need to direct their personnel in conjunction with the overall

objectives and strategy. We cannot let tactics drive the decision making process. It isperceived that suppression tactics in the alley on the D-side may have driven decision

making, as opposed to objectives and strategy driving the decisions. When there is little

to save, we should risk very little.

Cultural norms are not of necessity detrimental to safety. Some norms provide this department

strength. But the cultural norms that work against the safety of firefighters are and can

potentially be disastrous and should not be tolerated.

Equipment

It is departmental policy that, whenever entering any type of structure, every person carry their

assigned portable radio. After reviewing the interviews of those firefighters at the scene, it was

determined that not all radio transmissions were heard during this incident. It should also be

noted that numerous members working on the C and D side at the time of the collapse reported

that they had their radio donned but failed to hear the notification of the collapse zone or

emergency tones. The current radio system has had technical issues that have required

adjustments and a Labor/Management Project Team was formed in 2013 to identify and fix


31/71



problems with the system. The result of this examination was the Labor/Management decision to

utilize a trunked radio system for tactical fire ground communications. While not a contributing

factor in the collapse, communication challenges increase the complexity of the response and

rescue effort.

No other PPE was found to be an issue at this incident.

Limitations

Whenever any public safety organization loses one or more of their valiant servants, the impact

is destructive. The tragic results of this incident impacted the organization equally as a whole.

All of the stages of the grief process hold true for organizations as well. In January, 2016 the

Fire Chief assigned the task to investigate this incident to the team listed in this report. The

report was compiled in 12 weeks.

Information from previous interviews, interviews conducted by the investigation team,

recordings, and results from the formal AAR were utilized in the formation of the material

presented


32/71



Recommendations

Recommendation #1

The department should develop a Collapse Zone policy. Currently, the fire department does not

have a specific policy addressing Collapse Zones. This policy should be developed utilizing

NFPA, NIOSH, IFSTA and other industry recognized standards and recommendations as

reference. This policy should include the visual identification of establishing Collapse Zones

such as by lighted beacons or colored incident scene tape.

Recommendation #2

The department should update current communication policies as they apply to emergency

incidents. Currently, the department does not employ a uniform applied to radio

communications. The policies addressing critical information exchange should be updated. Theinvestigative team also identified the need to establish departmental procedures regarding

confirmation of critical emergency incident communications. Much in the same manner as we

conduct PAR procedures, these confirmation steps should be employed for every major

benchmark within an incident. The investigation team has concluded that GAG 3-4,Radio

Communications,should contain updated information regarding radio call procedures.

Recommendation #3

The department should develop an inclusive training program that revolves around the merits of

Situational Awareness. The Incident Commander is specifically responsible for managing risk at

the incident, however, one person cannot be expected to apply these principles to an incident if

the organization has not integrated a standard approach to risk management into its policies and

its organizational culture. Firefighters and fire officers should be trained and a system should be

implemented to outline clear rules of engagement and initial scene size-up. The risk versus

reward methodology should be employed.. This recommendation coincides with Goal 5 of the

departments strategic plan (2014):Provide comprehensive training and professional

development to ensure personnel are fully prepared to effectively perform their duties and

responsibilities.

Recommendation #4

The departments current Incident Management System Manual needs to be updated to include

current practices and new standards. The following bullets identify the elements of this policy

that should be included or updated.

When, where, and how IMS should be employed.

Clear instruction on how emergency incidents should be organized at the tactical level.


33/71



The IC should have a dedicated Safety Officer on all incidents.

The IC should develop a survivability profile when determining offensive or defensive

operations.

The initial size-up should consider the type and condition of structure to determine

possible structural weakness.

The creation of major incident benchmarks and the announcement and verification of

these benchmarks (such as the departments current PAR procedures).

The establishment and verbal announcement by the Communications Center as it

pertains to the construction of a 20-minute clock that is communicated to the Incident

Commander.

The review and changes to the departments IMS manual should refer to: NFPA 1500, Standard

on Fire Department Occupational Safety and Health Program; NFPA 1561, Standard on

Emergency Services Incident Management System; and the National Incident Management

System.

Recommendation #5

Train all department officers regarding Safety Officer duties and responsibilities. One critical

characteristics of the Safety Officer function is t that this incident function is not task oriented.

The responsibility of this IMS function is overall scene safety. This recommendation coincides

with Objective 3K of the departments strategic plan (2014):Define the role and function of the

Safety Officers.

Recommendation #6

Train all emergency personnel in building construction. Building construction has drastically

changed of the last two decades. It is imperative that this organization recognize critical

structural weaknesses and signs of collapse. The knowledge gained through this department

training should be incorporated into all scene size-ups given by the first arriving officer. This

recommendation coincides with Goal 5 of the departments strategic plan (2014):Provide

comprehensive training and professional development to ensure personnel are fully prepared to

effectively perform their duties and responsibilities.

Recommendation #7

Ensure that all personnel properly wear all assigned Personal Protective Equipment when

required by policy. The organizational culture that allows for varying interpretations regarding

when and where PPE should be donned must be terminated. This recommendation coincides

with Objective 3G of the departments strategic plan (2014):Develop an organizational strategy

to promote consistent use of personal protective equipment (PPE) to reduce potential for injury.


34/71



Recommendation #8

Develop, train and employ an Incident Accountability System for use in all emergency incidents.

The department currently has a general operating guidline establishing a departmental

accountability system (GOG 11-9). The details of this policy deal with the administration of an

accountability system at emergency and non-emergency scenes. Impractical, outdated, andinefficient for emergency scene use, the policy has lacked consistent utilization from its first

implementation. This recommendation coincides with Goal 7 of the departments strategic plan

(2014):Develop an updated KCFD incident management accountability system

Recommendation #9

The fire department should consider preparing, training, and implementing new policies and

procedures in a different format. Currently the department has over 200 policies, directives,

GAGs and GOGs. In order to update and reorganize our current system, we must identify

operational polices that should not be deviated from. Calling our operational proceduresGeneral Operating Guidelines(GOGs) versus Standard Operating Procedures (SOPs) may

imply that there is flexibility in complying with any given policy. There is no legal difference

between GOG vs SOP. All policies and procedures must comply with state and federal

regulations such as OSHA, NFPA, and the Code of Federal Regulations and should be cross-

referenced to these standards. A procedure for an annual review of all policies and procedures

should be implemented.

Recommendation #10

The department should develop a policy that addresses the formation of an investigation team

concept to be employed in any serious injury incidents. The following resources are

recommended for utilization and construction of this policy: LODD or Injury Investigation

guides published by IAFF/IAFC; NFPA 1500, Standard on Fire Department Occupational

Safety and Health Programand NFPA 1521, Standard onSafety Officer Professional

Qualifications. By preparing in advance, the department will ensure that we are able to handle at

least some of the myriad items that must be dealt with after a serious incident such as the

Independence Avenue fire. Other organizations have developed Health and Safety Units that

hold the responsibilities mentioned in this recommendation.

Recommendation #11

The Department should develop and implement a behavioral health training, referral and

educational program that also addresses peer counseling, suicide prevention and intervention.

Not all firefighters will need this service or take advantage of it. The construction of this team is

crucial to ensuring the emotional health and recuperation of department members. Although not

a contributing factor to the collapse, the department experienced many challenges that were a

direct result from this incident. The construction of this program is crucial to ensuring the


35/71



behavioral and emotional health and recuperation of the members of the Kansas City, Missouri

Fire Department. Recommended resources include the IAFF/IAFC Wellness Fitness Initiative,

and NFPA 1500, Standard on Fire Department Occupational Safety and Health Program.

Recommendation #12

The Department should review the current May-Day GOG and update to include new

communication considerations. The investigation team identified a possible element of

confusion within the application of procedures outlined in the policy. After many years of

successful implementation, this policy has provided a foundation for signaling of firefighters in

distress. The review of this policy is recommended that also includes a regional perspective.

Recommendation #13

The Department should further develop leadership and foster management capabilities as part of

an Officer Development program. This should include elements of supervision at both

emergency incidents and non-emergency situations. Achieving this recommendation will

position the department to be better prepared in the area of succession planning. The following

resources are recommended for building the framework for this program: the IAFC Officer

Development Handbook; NFPA 1021, Standard for Fire Officer Professional Qualifications,and

NFPA 1026,Incident Management Personnel Professional Qualifications; and the Kansas City,

Missouri Human Resources Academy coursework.

Recommendation #14

The Department should enhance its current building data collection methods utilized by

emergency operations and integrate high hazard risk identification with Fire Prevention records.Pre-fire tactical preplanning should be considered in all areas of the city. Inspection records

should be interchangeable between divisions within the department. Identification and visiting

target hazards that have multiple violations will give primary response companies knowledge

that may impact interior firefighting tactics and strategy. This policy should be developed

utilizing the standards presented in NFPA 1620, Standard on Pre-Incident Planning,as a

reference.


36/71



Closing

It is hard for the written word to capture the true event which transpired that horrible evening in

October, 2015. It is the hope of this Investigation Team that this report will be utilized as a

beginning step in a process that ensures that this type of tragedy does not repeat itself. Utilizing

the resources within this document will assist the organizations learning process as we move our

understanding of emergencies even further.

No one factor led to the wall collapse that ultimately took the lives of FAO Leggio and

Firefighter Mesh. However, it is comprehended departmentally that the enhanced knowledge of

fire behavior as well as the development of situational awareness skills will provide improved

organizational understanding of risk.

The Kansas City Missouri Fire Department performs hundreds of emergency scene operations

every single day with skill and precision. Let it be recognized that on the night of October 12,

2015, at 2608 Independence Avenue, hundreds of tasks and operations were performed

honorably, correctly, and without flaw, both before the collapse and after. In this recognition, let

us also have the humility and resolve to evaluate ourselves fairly. We owe it to each other. We

owe it to John and Larry. This investigation is an attempt to fulfill this obligation.


37/71



References

Alexandria Virginia Fire Department. (2012). Line of Duty Death Investigative Report:Medic

II Joshua A. Weissman.

Houston Fire Department. (2013). Firefighter Fatality Investigation.

International Association of Fire Chiefs. (2010). Officer Development Handbook. Alexandria,

VA: Author.

Kansas City Fire Department. (2014). Strategic Plan. Available atwww.kcmo.gov/fire

National Fire Protection Association. NFPA 1021: Standard for Fire Officer Professional

Qualifications. Quincy, MA: Author.

National Fire Protection Association. NFPA1026: Standard for Incident Management

Personnel Qualifications. Quincy, MA: Author.

National Fire Protection Association. NFPA1500: Standard on Fire Department Occupational

Health and Safety Program. Quincy, MA: Author.

National Fire Protection Association. NFPA1521: Standard for Fire Department Safety Officer

Professional Qualifications. Quincy, MA: Author.

National Fire Protection Association. NFPA1561: Standard on Emergency Service Incident

Management System and Command Safety. Quincy, MA: Author.

National Fire Protection Association. NFPA 1620: Standard for Pre-Incident Planning.

Quincy, MA: Author.

Shappell, S. A, & Weigmann, D. A. (2000). The Human Factors Analysis and Classification

System-HFACS. Office of Aviation Medicine. Washington DC: US Department of

Transportation.
http://www.kcmo.gov/firehttp://www.kcmo.gov/firehttp://www.kcmo.gov/firehttp://www.kcmo.gov/fire


38/71




39/71



Glossary of Terms

AAR: is a structured review or de-brief process for analyzing what happened, why it happened,

and how it can be done better by the participants and those responsible for the project or event.

After-action reviews in the formal sense were originally developed by the U.S. Army although

less structured de-briefs after events have existed since time immemorial.

Advanced Life Support (ALS): A level of care provided by pre-hospital emergency medical

services. Advanced life support consists of invasive life-saving procedures including the

placement of advanced airway adjuncts, intravenous infusions, manual defibrillation,

electrocardiogram interpretation, and much more.

ALS Pumper:The KCFD suppression apparatus that is primarily responsible for providing

advanced medical care at any emergency medical incident. This apparatus is staffed full time

with a licensed paramedic and works closely with the EMS crews on the ambulances in

providing advanced medical care. The staffing reflects the staffing of a pumper.

ATF: Alcohol Tobacco and Firearms; the abbreviated acronym for the federal agency organized

under the Department of Justice.

Basic Life Support (BLS): A level of medical care provided by pre-hospital emergency medical

services. Basic life support consists of essential, non-invasive life-saving procedures including

CPR, bleeding control, splinting broken bones, artificial ventilation, and basic airway

management.

Battalion: The formal designation used by KCFD to divide Kansas City Missouri into

geographical areas or primary responsibility. KCFD currently operates 7 battalions.

BLS Pumper: The KCFD suppression apparatus that is primarily responsible for providing

immediate basic life support for patients at emergency medical scenes until a crew with a higher

level of medical training can arrive and provide ALS care at an emergency medical scene. The

staffing reflects the staffing of a pumper.

Bureaus: The formal designation used by KCFD to designate specialized areas of responsibility

within the department. KCFD currently operates with 8 bureaus.

Car: The informal designation used by KCFD to designate the Battalion Chiefs vehicle.

Centrally Monitored Fire Alarm Systems: a company that provides services to monitor burglar,

fire and residential alarm systems.

Command Board: A visual aid used by the fire service to provide incident commanders a better

awareness of the objectives at an emergency scene.


40/71



Communications Center (Dispatch): Dispatch personnel are responsible for the operations of the

Communications Center in accordance with applicable protocol. Dispatch receives requests for

all Fire Department services; dispatches the appropriate unit, and coordinates the system to

assure readiness. Provides appropriate pre-arrival instructions to callers, and field personnel, and

continuously monitor and apply system operations that maintain coverage and efficiency of the

Fire System.

Community Risk Management: the identification and prioritization of risks, followed by the

coordinated application of resources to minimize the probability of occurrence and/or the impact

of unfortunate events.

Company Officer: The designation used by KCFD to describe the Captains position in the

organization. Both terms can be used interchangeably.

Daily Deployment: The staffing levels of KCFD equipment and personnel as provided to the city

on a daily basis.

Department of Defense: is an executive branch department of the federal government of the

United States charged with coordinating and supervising all agencies and functions of the

government concerned directly with national security and the United States Armed Forces.

Defensive: Fire attack tactic used by KCFD by which KCFD crews extinguish a structure fire

from the exterior of the building. Such tactic is used when the Incident Commander determines

there is too great of a risk to perform an aggressive interior attack or search and rescue

operations.

Division Group Supervisor: The Supervisor is responsible for the implementation of the assignedportion of the Incident Action Plan (IAP), assignment of resources within the Division/Group,

and reporting on the progress of control operations and status of resources within the

Division/Group.

Dynamic ALS Shift:The KCFD medical apparatus that works on a 10 hour rotating shift

consisting of a paramedic and EMT.

Emergency Medical Services (EMS): type of emergency service dedicated to providing out-of-

hospital acute medical care and/or transport to definitive care, to patients with illnesses and

injuries which the patient, or the medical practitioner, believes constitute a medical emergency.

The use of the term emergency medical services may solely refer to the re-hospital element of

the care or be part of an integrated system of care, including the main care provider, such as a

hospital.


41/71



Emergency Medical Technician (EMT): EMT personnel are responsible for patient care at the

BLS level according to patient care modalities in accordance with all applicable federal, state

and local laws, regulations, statutes and protocols. All EMT personnel shall comply with and

perform patient care based strictly upon the policies set forth by the Emergency Physicians

Advisory Board (EPAB) and the Medical Director.

FAO: The designation used by KCFD for the member whos primary daily responsibility is to

operate the suppression apparatus.

Firefighter: The designation used by KCFD for the member whos primary responsibility is to

support suppression and EMS operations while being supervised by a company officer.

Firefighter Fatigue: as described in the IAFF report Contributing Factors to Firefighter LODD

injury in Metro size Fire Departments in the United States, weariness caused by exertion. It can

describe a range of afflictions, varying from a general state of lethargy to a specific work-

induced burning sensation within one's muscles. It can be both physical and mental. Physicalfatigue is the inability to continue functioning at the level of one's normal abilities, (Hawley,

7:97).

Firefighter Near Miss Reporting System: The National Firefighter Near Miss Reporting System

was launched August 2005 at Fire Rescue International.

Fire ground transmission: Radio communications on the fire ground.

Fire Suppression: The physical acts of extinguishing the fire.

Functional Command: A command organization based on fire department functions rather than

geographic areas.

GAG: (General Administrative Guideline)

GOG: (General Operating Guideline)

HazMat: KCFD division with the primary responsibility of operating and mitigating operations

involving both known and unknown chemical hazards on emergency scenes.

HFACS: (The Human Factors Analysis and Classification System) developed by Dr. Scott

Shappell and Dr. Doug Wiegmann. It is a broad human error framework that was originally used

by the US Air Force to investigate and analyze human factors aspects of aviation. The HFACS

framework provides a tool to assist in the investigation process and target training and prevention

efforts.

IMS: a standardized approach to incident management developed by the Department of

Homeland Security. Also known as NIMS-National Incident Management System.


42/71



IMS Form: Documents used to plan and track events and resources at an incident.

Incident Command: a standardized approach to the command, control, and coordination of

emergency response providing a common hierarchy within which responders from multiple

agencies can be effective.

Incident Safety Officer: is a member of the "Command Team". This person works directly under

and with the incident commander (IC) to help manage the risks that our members take at

emergencies.

Incipient stage: 29 CFR 1910.155(c)(26) defines "incipient stage fire" as a fire which is in the

initial or beginning stage and which can controlled or extinguished by portable fire extinguishers,

class II standpipe or small hose systems without the need for protective clothing or breathing

apparatus.

KSAs: an acronym that stands for Knowledge, Skills, and Abilities. A detailed list of the

qualifications, i.e., the Knowledge, Skills, and Abilities, that a person needs to perform a specific

job.

May Day:An emergency radio message used by a lost, trapped, or injured firefighter, or any

other KCFD personnel reporting the knowledge of a lost, trapped, or injured member of KCFD.

Reference KCFD GOG 11-2.

National Institute for Occupational Safety and Health (NIOSH): The National Institute for

Occupational Safety and Health (NIOSH) is the federal agency responsible for conducting

research and making recommendations for the prevention of work-related injury and illness.

NIOSH conducts independent investigations of firefighter line of duty deaths.

NFPA 1500:National Fire Protection Association Standard on Fire Department Occupational

Safety and Health Program.

NFPA 1561: National Fire Protection Association Standard on Emergency Services Incident

Management System

NIMS: a systematic, proactive approach to guide departments and agencies at all levels of

government, nongovernmental organizations, and the private sector to work together seamlessly

and manage incidents involving all threats and hazardsregardless of cause, size, location, or

complexityin order to reduce loss of life, property and harm to the environment.

PAR: Personal Accountability Report is a communication, either by radio or face to face,

between on-scene personnel and the Incident Commander or their designee. A roll call (PAR) of

on-scene personnel shall be completed immediately upon orders of the Incident Commander or

other officer operating within the command structure fire.


43/71



Paramedic (MEDIC): Pre-hospital personnel responsible for all patient care (ALS as well as

BLS) according to patient care modalities in accordance with all applicable federal, state and

local laws, regulations, statutes and protocols. All Paramedic personnel shall comply with and

perform patient care based strictly upon the policies set forth by the Emergency Physicians

Advisory Board (EPAB) and the Medical Director

Pumper: The KCFD suppression apparatus that is primarily responsible for attacking and

extinguishing a fire. KCFD pumpers supply water to other pumpers engaged in fire attack. They

supply water to fire protection systems and standpipes as well as supplying water to master

stream appliances like those found on truck companies. KCFD staffs all pumpers with 4

personnel that consist of a Captain, a Fire Apparatus Operator (FAO) and two firefighters

Radio Traffic: Verbal communications broadcast over the KCFD radio system.

Rapid Intervention Team (RIT): a team of four firefighters dedicated solely to the search and

rescue of other firefighters in distress.

Rescue Vehicle: See Technical Rescue

Run Report:the prepared account of a particular event, happening, or incident. The term run

report is synonymous with and used interchangeably with the term incident report. Utilizing the

National Fire Incident Reporting System (NFIRS) standard, the run report is the method by

which fire departments uniformly report to the U.S. Fire Administration (USFA) on the full

range of their activities, from fire to Emergency Medical Services (EMS) to equipment involved

in the response.

SCBA:Self-Contained Breathing Apparatus

Sectors: BranchA supervisory level above division, group, or sector, designed to provide span

of control at a high level. A branch is usually applied to the operations or logistics sections and is

usually identified by a Roman numeral or functional name.

Static ALS Ambulance:The KCFD medical apparatus that works on a 24 hour rotating shift

consisting of a paramedic and EMT that primarily operates out of one of the KCFD fire station.

Strategic Plan: an organizational management activity that is used to set priorities, focus energy

and resources, strengthen operations, ensure that employees and other stakeholders are working

toward common goals, establish agreement around intended outcomes/results, and assess andadjust the organization's direction in response to a changing environment.

Technical Rescue: The KCFD suppression apparatus that is primarily responsible for Forcible

entry, ventilation, utility control, salvage, and overhaul at the fire scene. KCFD operates the

heavy rescue version of the rescue company. Th